Age-associated changes in electrophysiologic remodeling: a potential contributor to initiation of atrial fibrillation

OBJECTIVE: Although the incidence of atrial fibrillation (AF) increases with age, the cellular electrophysiological changes that render the atria of aged individuals more susceptible to AF remain poorly understood. We hypothesized that dispersion of atrial repolarization increases with aging, creating a substrate for initiation of AF. METHODS: Four groups of dogs were studied: adult and old dogs in normal sinus rhythm (SR) and adult and old dogs with chronic AF (CAF) induced by rapid atrial pacing. In each dog, action potentials (AP) were recorded with microelectrodes from isolated endocardial preparations of four regions of right atrium and three regions of left atrium. Two indices of AP duration (APD) heterogeneity were obtained in each dog by calculating standard deviation (SD) and the coefficient of variation (COV=[SD/mean] x 100%). RESULTS: In SR groups, APD averaged across all regions was significantly longer in old than in adult tissues. Both indices of APD heterogeneity were higher in old dogs in comparison to adult. At both ages, CAF was associated with significant APD shortening and a decrease in APD adaptation to rate. While CAF significantly increased both indices of APD heterogeneity in adult dogs, it significantly decreased them in old dogs. CONCLUSIONS: The increase of spatial variability in repolarization in old atria may contribute to the initiation of AF in the aged. CAF-induced APD shortening and a decrease in APD adaptation appear to be important for the maintenance of sustained AF in both adult and old atria. The CAF-induced increase in dispersion of repolarization may be important for AF stabilization in adults, while previously reported fibrosis and slowed conduction of premature beats may be important in the old for both AF initiation during SR and subsequent stabilization of AF.     

Novel breathing motion model for radiotherapy

PURPOSE: An accurate model of breathing motion under quiet respiration is desirable to obtain the most accurate and conformal dose distributions for mobile lung cancer lesions. On the basis of recent lung motion measurements and the physiologic functioning of the lungs, we have determined that the motion of lung and lung tumor tissues can be modeled as a function of five degrees of freedom, the position of the tissues at a user-specified reference breathing phase, tidal volume and its temporal derivative airflow (tidal volume phase space). Time is an implicit variable in this model. METHODS AND MATERIALS: To test this hypothesis, a mathematical model of motion was developed that described the motion of objects p in the lungs as linear functions of tidal volume and airflow. The position of an object was described relative to its position -->P0 at the reference tidal volume and zero airflow, and the motion of the object was referenced to this position. Hysteresis behavior was hypothesized to be caused by pressure imbalances in the lung during breathing and was, in this model, a function of airflow. The motion was modeled as independent tidal volume and airflow displacement vectors, with the position of the object at time t equal to the vector sum -->rP(t) = -->rv(t) + -->rf(t) where -->rv(t) and -->rf(t) were displacement vectors with magnitudes approximated by linear functions of the tidal volume and airflow. To test this model, we analyzed five-dimensional CT scans (CT scans acquired with simultaneous real-time monitoring of the tidal volume) of 4 patients. The scans were acquired throughout the lungs, but the trajectories were analyzed in the couch positions near the diaphragm. A template-matching algorithm was implemented to identify the positions of the points throughout the 15 scans. In total, 76 points throughout the 4 patients were tracked. The lateral motion of these points was minimal; thus, the model was described in two spatial dimensions, with a total of six parameters necessary to describe the 30 degrees of freedom inherent in the 15 positions. RESULTS: For the 76 evaluated points, the average discrepancy (the distance between the measured and prediction positions) of the 15 locations for each tracked point was 0.75 +/- 0.25 mm, with an average maximal discrepancy of 1.55 +/- 0.54 mm. The average discrepancy was also tabulated as a fraction of the breathing motion. Discrepancies of <10% and 15% of the overall motion occurred in 73% and 95% of the tracked points, respectively. CONCLUSION: The motion tracking algorithms are being improved and automated to provide more motion data to test the models. This may allow a measurement of the motion-fitting parameters throughout the lungs. If the parameters vary smoothly, interpolation may be possible, yielding a continuous mathematical model of the breathing motion throughout the lungs. The utility of the model will depend on its stability as a function of time. If the model is only robust during the measurement session, it may be useful for determining lung function. If it is robust for weeks, it may be useful for treatment planning and gating of lung treatments. The use of tidal volume phase space for characterizing breathing motion appears to have provided, for the first time, the potential for a patient-specific mathematical model of breathing motion.     

Our experience with pectoralis major flap for management of sternal dehiscence: A review of 25 cases

Objective:

To report our experience of the pectoralis major flap as the treatment modality for post coronary artery bypass sternal wound dehiscence.

Materials and Methods:

A retrospective study of 25 open heart surgery cases, performed between January 2006 and December 2010 at Deenanath Mangeshkar Hospital, Pune, was carried out. Unilateral or bilateral pectoralis major muscle flap by the double breasting technique using rectus extension was used in the management of these patients. The outcome was assessed on the basis of efficacy of flap surgery in achieving wound healing and post-surgery shoulder joint movements to evaluate donor site morbidity. The follow-up ranged from 5 months to 3.5 years.

Results:

Twenty-three (92%) patients were discharged with complete wound closure. One patient (4%) had wound dehiscence after flap surgery. One patient (4%) died in the hospital in the immediate postoperative period due to mediastinitis. No recurrent sternum infection has occurred till date in 24 patients (96%). For one patient (4%) who had wound dehiscence, daily dressing was done and wound healing was achieved with secondary intension. At follow-up, shoulder joint movements were normal in all the patients.

Conclusions:

The double breasting technique of the pectoralis major muscle flaps with rectus sheath extension is efficient in covering the entire length of the defect and can reduce the morbidity, without affecting the function of the shoulder joint.KEY WORDS: Bilateral pectoralis major flaps, left internal mammary artery and right internal mammary artery, sternal dehiscence     

Development of spray-dried co-precipitate of amorphous celecoxib containing storage and compression stabilizers

The purpose of this study was to obtain an amorphous system with minimum unit operations that will prevent recrystallization of amorphous drugs since preparation, during processing (compression) and further storage. Amorphous celecoxib, solid dispersion (SD) of celecoxib with polyvinyl pyrrollidone (PVP) and co-precipitate with PVP and carrageenan (CAR) in different ratios were prepared by the spray drying technique and compressed into tablets. Saturation solubility and dissolution studies were performed to differentiate performance after processing. Differential scanning calorimetry and X-ray powder difraction revealed the amorphous form of celecoxib, whereas infrared spectroscopy revealed hydrogen bonding between celecoxib and PVP. The dissolution profile of the solid dispersion and co-precipitate improved compared to celecoxib and amorphous celecoxib. Amorphous celecoxib was not stable on storage whereas the solid dispersion and co-precipitate powders were stable for 3 months. Tablets of the solid dispersion of celecoxib with PVP and physical mixture with PVP and carrageenan showed better resistance to recrystallization than amorphous celecoxib during compression but recrystallized on storage. However, tablets of co-precipitate with PVP and carageenan showed no evidence of crystallinity during stability studies with comparable dissolution profiles. This extraordinary stability of spray-dried co-precipitate tablets may be attributed to the cushioning action provided by the viscoelastic polymer CAR and hydrogen bonding interaction between celecoxib and PVP. The present study demonstrates the synergistic effect of combining two types of stabilizers, PVP and CAR, on the stability of amorphous drug during compression and storage as compared to their effect when used alone.     

Comparative Evaluation of Disodium Edetate and Diethylenetriaminepentaacetic Acid as Iron Chelators to Prevent Metal -Catalyzed Destabilization of a Therapeutic Monoclonal Antibody

Understanding the effect of metal chelators with respect to their ability to inhibit metal catalyzed degradation in biologic products is a critical component for solution formulation development. Two metal chelators, disodium edetate (Na₂EDTA) and diethylenetriaminepentaacetic acid (DTPA), were evaluated for their ability to stabilize IgG2 mAb in solution formulations spiked with various levels of iron. Real-time stability attributes such as oxidation, soluble aggregate formation, deamidation and fragmentation demonstrated that DTPA was equivalent to Na₂EDTA with respect to inhibiting iron-induced degradation over the range of iron concentrations studied. When sufficient chelator was present to stoichiometrically complex trace iron contamination, both Na2EDTA and DTPA exhibited the capacity to reduce protein degradation. However, sub-stoichiometric ratios of both chelators were unable to inhibit the degradation induced by free iron ions, which were found to bind weakly to the mAb. This bound iron did not measurably alter the secondary or the tertiary structure of the mAb, but appeared to decrease its intrinsic thermodynamic stability, probably by causing subtle perturbations in the tertiary structure. These destabilization effects were not observed when the chelators were present at stoichiometric ratios highlighting the feasibility of using DTPA as an alternate trace metal chelator to Na₂EDTA in biologic protein formulations.     

Neurobehavioral disorders in children, adolescents, and young adults with Down syndrome

The term dual-diagnosis refers to a person with mental retardation and a psychiatric disorder. Most children with Down syndrome (DS) do not have a psychiatric or neurobehavioral disorder. Current prevalence estimates of neurobehavioral and psychiatric co-morbidity in children with DS range from 18% to 38%. We have found it useful to distinguish conditions with a pre-pubertal onset from those presenting in the post-pubertal period, as these are biologically distinct periods each with a unique vulnerability to specific psychiatric disorders. Due to the increased recognition that psychiatric symptoms may co-occur with mental retardation, and are not inextricably linked to cognitive impairment, these conditions are considered treatable, in part, under a medical model. Improvement in physiologic regulation, emotional stability, and neurocognitive processing is one of the most elusive but fundamental goals of pharmacologic intervention in these disorders.